Policy Support For Patient-Centered Care: The Need For Measurable Improvements In Decision Quality

Abstract

The phenomenon of practice variation draws attention to the need for better management of clinical decision making as a means of ensuring quality. Different policies to address variations, including guidelines and measures of appropriateness, have had little demonstrable impact on variation itself or on the underlying quality problems. Variations in rates of interventions raise questions about the patient-centeredness of decisions that determine what care is provided to whom. Policies that support the development and routine use of measures of decision quality will provide opportunities to measurably improve the quality of decisions, thereby leading to more patient-centered and efficient health care. S t r i k i n g va r i at i o n s i n r at e s of common surgical procedures among seemingly similar populations have been documented for more than sixty years. Variation is greatest when there is legitimate discretion about the best course of action. 1 Sometimes this discretion exists because of inadequate research and the resulting collective professional uncertainty about the effectiveness of an intervention. Sometimes research is adequate but is variably interpreted or disseminated, which results in individual professional uncertainty. In some cases, two or more interventions may be equally effective. Under these circumstances, local conventional wisdom shaped by the beliefs of local medical opinion leaders can take over, masking uncertainty and driving procedure rates in one direction or the other. The result is often an idiosyncratic pattern of rates that John Wennberg has labeled the "surgical signature" of a particular geographic area. 2 The cost and quality implications of these geographic differences are too great to be ignored. 3 One response of policymakers to practice variation has been to urge professional organizations and researchers to develop clinical practice guidelines to as-VA R -5 4 7 O c t o b e r 2 0 0 4

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